Abstract
Our purpose was to project and compare clinical and quality-adjusted life year (QALY) outcomes of adjuvant radiotherapy (ART) versus salvage RT (SRT) after radical prostatectomy for men with locally advanced prostate cancer. We constructed a Markov model to simulate the randomized studies of observation versus ART, assuming 75% of observation patients would receive SRT at PSA recurrence. Transition probabilities and utility inputs were drawn from randomized trials of ART and cohort studies of SRT. We projected 10-year PSA recurrence-free survival, metastasis-free survival and overall survival. We found that observation with selective SRT yielded slightly worse outcomes than ART for post-RT PSA recurrence-free survival (47 and 52%), metastasis-free survival (69 and 70%) and overall survival (72 and 73%). Findings were robust to sensitivity analyses. After adjusting for the disutility of RT, observation plus SRT yielded better QALYs at 10 years than ART (6.80 and 6.13 QALYs). Thus, observation plus SRT may be optimal for men likely to comply with surveillance who wish to minimize side effects of the treatment. These findings reflect outcomes for the average patient given the current level of evidence and are meant to help inform current decision-making as we await future clinical studies of comparative effectiveness.
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References
Surveillance, Epidemiology, and End Results (SEER). Program (www.seer.cancer.gov.) Limited-Use Data (1973–2006), National Cancer Institute, released April 2009.
Stephenson AJ, Scardino PT, Eastham JA, Bianco Jr FJ, Dotan ZA, DiBlasio CJ et al. Postoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy. J Clin Oncol 2005; 23: 7005–7012.
Bolla M, van Poppel H, Collette L, van Cangh P, Vekemans K, Da Pozzo L et al. Postoperative radiotherapy after radical prostatectomy: a randomised controlled trial (EORTC trial 22911). Lancet 2005; 366: 572–578.
Stephenson AJ, Scardino PT, Kattan MW, Pisansky TM, Slawin KM, Klein EA et al. Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy. J Clin Oncol 2007; 25: 2035–2041.
Swanson GP, Goldman B, Tangen CM, Chin J, Messing E, Canby-Hagino E et al. The prognostic impact of seminal vesicle involvement found at prostatectomy and the effects of adjuvant radiation: data from Southwest Oncology Group 8794. J Urol 2008; 180: 2453–2457; discussion 2458.
Thompson Jr IM, Tangen CM, Paradelo J, Lucia MS, Miller G, Troyer D et al. Adjuvant radiotherapy for pathologically advanced prostate cancer: a randomized clinical trial. JAMA 2006; 296: 2329–2335.
Wiegel T, Bottke D, Steiner U, Siegmann A, Golz R, Storkel S et al. Phase III postoperative adjuvant radiotherapy after radical prostatectomy compared with radical prostatectomy alone in pT3 prostate cancer with postoperative undetectable prostate-specific antigen: ARO 96-02/AUO AP 09/95. J Clin Oncol 2009; 27: 2924–2930.
Moinpour CM, Hayden KA, Unger JM, Thompson Jr IM, Redman MW, Canby-Hagino ED et al. Health-related quality of life results in pathologic stage C prostate cancer from a Southwest Oncology Group trial comparing radical prostatectomy alone with radical prostatectomy plus radiation therapy. J Clin Oncol 2008; 26: 112–120.
Thompson IM, Tangen CM, Paradelo J, Lucia MS, Miller G, Troyer D et al. Adjuvant radiotherapy for pathological T3N0M0 prostate cancer significantly reduces risk of metastases and improves survival: long-term followup of a randomized clinical trial. J Urol 2009; 181: 956–962.
Buskirk SJ, Pisansky TM, Schild SE, Macdonald OK, Wehle MJ, Kozelsky TF et al. Salvage radiotherapy for isolated prostate specific antigen increase after radical prostatectomy: evaluation of prognostic factors and creation of a prognostic scoring system. J Urol 2006; 176: 985–990.
Catton C, Gospodarowicz M, Warde P, Panzarella T, Catton P, McLean M et al. Adjuvant and salvage radiation therapy after radical prostatectomy for adenocarcinoma of the prostate. Radiother Oncol 2001; 59: 51–60.
Chawla AK, Thakral HK, Zietman AL, Shipley WU . Salvage radiotherapy after radical prostatectomy for prostate adenocarcinoma: analysis of efficacy and prognostic factors. Urology 2002; 59: 726–731.
Katz MS, Zelefsky MJ, Venkatraman ES, Fuks Z, Hummer A, Leibel SA . Predictors of biochemical outcome with salvage conformal radiotherapy after radical prostatectomy for prostate cancer. J Clin Oncol 2003; 21: 483–489.
Macdonald OK, D’Amico AV, Sadetsky N, Shrieve DC, Carroll PR . Predicting PSA failure following salvage radiotherapy for a rising PSA post-prostatectomy: from the CaPSURE database. Urol Oncol 2008; 26: 271–275.
Taylor N, Kelly JF, Kuban DA, Babaian RJ, Pisters LL, Pollack A . Adjuvant and salvage radiotherapy after radical prostatectomy for prostate cancer. Int J Radiat Oncol Biol Phys 2003; 56: 755–763.
Trabulsi EJ, Valicenti RK, Hanlon AL, Pisansky TM, Sandler HM, Kuban DA et al. A multi-institutional matched-control analysis of adjuvant and salvage postoperative radiation therapy for pT3-4N0 prostate cancer. Urology 2008; 72: 1298–1302; discussion 1302–1304.
Trock BJ, Han M, Freedland SJ, Humphreys EB, DeWeese TL, Partin AW et al. Prostate cancer-specific survival following salvage radiotherapy vs observation in men with biochemical recurrence after radical prostatectomy. JAMA 2008; 299: 2760–2769.
Parker C, Sydes MR, Catton CN, Kynaston H, Logue J, Murphy C et al. Radiotherapy and androgen deprivation in combination after local surgery (RADICALS): a new Medical Research Council/National Cancer Institute of Canada phase III trial of adjuvant treatment after radical prostatectomy. BJU Int 2007; 99: 1376–1379.
Thompson IM, Tangen CM, Klein EA . Is there a standard of care for pathologic stage T3 prostate cancer? J Clin Oncol 2009; 27: 2898–2899.
Pasquier D, Ballereau C . Adjuvant and salvage radiotherapy after prostatectomy for prostate cancer: a literature review. Int J Radiat Oncol Biol Phys 2008; 72: 972–979.
Anderson R . United States abridged life tables, 1996. National Vital Statistics Reports 1998; 47: 1–20.
Miller DK, Homan SM . Determining transition probabilities: confusion and suggestions. Med Decis Making 1994; 14: 52–58.
Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Waldron W et al (eds). SEER Cancer Statistics Review, 1975–2008, National Cancer Institute: Bethesda, MD, http://seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission, posted to the SEER web site, 2011.
Stout NK, Knudsen AB, Kong CY, McMahon PM, Gazelle GS . Calibration methods used in cancer simulation models and suggested reporting guidelines. Pharmacoeconomics 2009; 27: 533–545.
Stewart ST, Lenert L, Bhatnagar V, Kaplan RM . Utilities for prostate cancer health states in men aged 60 and older. Med Care 2005; 43: 347–355.
Krahn M, Ritvo P, Irvine J, Tomlinson G, Bremner KE, Bezjak A et al. Patient and community preferences for outcomes in prostate cancer: implications for clinical policy. Med Care 2003; 41: 153–164.
Arias E . United States life tables, 2004. Natl Vital Stat Rep 2007; 56: 1–39.
Mehta SS, Lubeck DP, Sadetsky N, Pasta DJ, Carroll PR . Patterns of secondary cancer treatment for biochemical failure following radical prostatectomy: data from CaPSURE. J Urol 2004; 171: 215–219.
Moreira DM, Banez LL, Presti Jr JC, Aronson WJ, Terris MK, Kane CJ et al. Predictors of secondary treatment following biochemical recurrence after radical prostatectomy: results from the Shared Equal Access Regional Cancer Hospital database. BJU Int 2010; 105: 28–33.
Zelefsky MJ, Levin EJ, Hunt M, Yamada Y, Shippy AM, Jackson A et al. Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys 2008; 70: 1124–1129.
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We acknowledge Dr Anne Marie Weber-Main for critically reviewing and editing manuscript drafts.
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Elliott, S., Wilt, T. & Kuntz, K. Projecting the clinical benefits of adjuvant radiotherapy versus observation and selective salvage radiotherapy after radical prostatectomy: a decision analysis. Prostate Cancer Prostatic Dis 14, 270–277 (2011). https://doi.org/10.1038/pcan.2011.27
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DOI: https://doi.org/10.1038/pcan.2011.27
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